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60- ,n— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY IYamauth I, MA DATE I 7-3 it J PERMIT# C.a.."1172
JOBSITE ADDRESS I "7 ('cid S y.412 I OWNER'SNAME I SteJ crri- I
GOWNER ADDRESS: I S,Qrn P I TEEN I FAX:I I
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW: , RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
FIXUTRES 7 FLOOR-. Bemt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER ^
COOK STOVE • t Ili
DIRECT VENT HEATER 4 I''" t I
DRYER I I ut y 3 ' 201. l u,i
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR ..
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
•
•I have a current liability Insurance policyor Its substantial INSURANCE COVERAGE
equivalent which meets the requirements of MGL Ch.142 YES a NO 0
If you have checked ygs,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POUCY' OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not havq the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application ytibeg this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT ❑
hereby certify that all chile dotage and information I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and Installation performed under the permit Issued for this application will be In compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME I M.41 "NCft14q/Yt_ I LICENSE#1,SD(w I SIGNATURE
COMPANY NAME:I roe ia.tridr (nes I ADDRESS:I /0(4) ,S7, / I
CITY: I (r„-F-ecucfl J STATE EH- ZIP. [(I►JePal. FAx I -41 Si-/is/ I
TEL iris r/SV3 I CELL:I J EMAIL: I
MASTER 0 JOURNEYMAMIZI LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0#LJ LLC❑#Q
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
JtOUCH GAS INSPECTION NOTES r
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT e •
FLAN REVIEW NOTES